Rev. bras. ortop. vol.52 número2

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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Original

article

Hip

disarticulation

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case

series

analysis

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literature

review

夽

Diogo

Lino

Moura

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_António

_Garruc¸o

CentroHospitalareUniversitáriodeCoimbra,DepartamentodeOrtopedia,Coimbra,Portugal

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Articlehistory:

Received14February2016 Accepted1September2016 Availableonline3March2017

Keywords: Hipjoint Disarticulation Amputation Lowerextremity Infection Tumor

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Objective:Topresentaretrospectivestudyof16patientssubmittedtohipdisarticulation. Methods:Duringtheperiodof16years,16patientswhounderwenthipdisarticulationwere identified.Allofthemwerestudiedbasedonclinicalrecordsregardingthegender,ageat surgery,disarticulationcause,postoperativecomplications,mortalityratesandfunctional statusafterhipdisarticulation.

Results:Hipdisarticulationwasperformedelectivelyinmostcasesandurgentlyinonly threecases.Theindicationshadthefollowingorigins:infection(n=6),tumor(n=6),trauma (n=3),andischemia(n=2).Themeanpost-surgerysurvivalwas200.5days.Thesurvival rateswere6875%aftersixmonths,5625%afteroneyear,and50%afterthreeyears.The mortalityrateswerehigherindisarticulationswithtraumatic(66.7%)andtumoral(60%) causes.Regardingtheeightpatientswhosurvived,halfofthemambulatewithcrutchesand withoutprosthesis,25%walkwithlimbprosthesis,and25%arebedridden.Complications andmortalitywerehigherinthecasesofurgentsurgery,andinthosewithtraumaticand tumoralcauses.

Conclusion:Hipdisarticulationisamajorablativesurgerywithobviousimplicationsforlimb functionality,aswellashighratesofcomplicationsandmortality.However,whenperformed atthecorrecttimeandwithproperindication,thisprocedurecanbelife-savingandcan ensurethereturntothehomeenvironmentwithacertaindegreeofqualityoflife.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽

StudyconductedattheCentroHospitalareUniversitáriodeCoimbra,DepartamentodeOrtopedia,Coimbra,Portugal.

∗ _{Correspondingauthor.}

E-mails:dflmoura@gmail.com,dflm12345@gmail.com(D.L.Moura). http://dx.doi.org/10.1016/j.rboe.2016.09.008

Desarticulac¸ão

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anca

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Análise

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série

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revisão

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literatura

Palavras-chave: Articulac¸ãodaanca Desarticulac¸ão Amputac¸ão Extremidadeinferior Infec¸ão

Tumor

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Objetivo:Apresentarumestudoretrospectivoem16pacientessubmetidosadesarticulac¸ão daanca.

Métodos: Foramidentificados16pacientessubmetidosadesarticulac¸ãodaancaaolongo de16anos.Todosforamestudadospormeiodosregistosclínicosquantoasexo,idadena cirurgia,causadadesarticulac¸ão,complicac¸õesnopós-operatório,índicesdemortalidade egraudefuncionalidadeapósadesarticulac¸ãodaanca.

Resultados: Adesarticulac¸ãodaancafoifeitaeletivamentenamaioriadassituac¸õese ape-nasdeformaurgenteemtrêscasos.Asindicac¸õestiveramasseguintesorigens:infecc¸ão (n=6),tumor(n=5),traumatismo(n=3)eisquemia(n=2).Otempomédioglobalde sobre-vivênciapós-cirurgiafoide200,5dias.Osíndicesdesobrevivênciaforamde68,75%após seismeses,56,25%apósumanoede50%apóstrêsanos.Osíndicesdemortalidadeforam maiselevadosnasdesarticulac¸õesdecausatraumática(66,7%)edecausatumoral(60%).Em relac¸ãoaosoitopacientesquepermanecemvivos,metadefazmarchacomapoiodemuletas canadensesesemprótese,25%fazemmarchacommembroprotéticoe25%encontram-se acamados.Astaxasdecomplicac¸õesemortalidadeforammaiselevadasnasdesarticulac¸ões urgentesenasefetuadasemconsequênciadetraumatismosetumores.

Conclusão: Adesarticulac¸ãodaancaéumacirurgiaaltamentemutilante,comimplicac¸ões óbviasnafuncionalidadedomembroetaxaselevadasdecomplicac¸õesemortalidade.No entanto,quandoefetuadoemummomentoadequadoecomindicac¸ãocorreta,esse pro-cedimentopodesalvaravidadopacienteegarantiroseuregressoaodomicíliocomalguma qualidadedevida.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Hip disarticulation is the amputation of the lower limb throughthehipjoint;itcontinuestobeoneofthemost radi-calproceduresinorthopedicsurgery.1,2_{Thissurgeryaccounts}

onlyforapproximately0.5%oflowerlimbamputations.1_The

mostfrequentindicationsarehighlyinvasivetumorsofthe musculoskeletalsystemthatareunresectablewithlimb con-servation,limbischemia,trauma,andseveremusculoskeletal infectionsofthepelvicregionand/orgroin.1

Material

and

methods

The authors present a series of 16 patients who under-wenthipdisarticulationoveraperiodof16years(1999–2015) at this institution, which includes centers dedicated to tumorsandsepticpathologyofthemusculoskeletalsystem. All patientswere characterizedand studied retrospectively through clinical records regarding gender, age at surgery, causeofdisarticulation,postoperativecomplications, mortal-ityrates,anddegreeoffunctionalityafterhipdisarticulation. Thevariables were analyzedusing SPSS, version23, and a 0.05significancelevelwasadopted.Quantitativevalueswere presentedasmean,minimum value,maximum value,and standarddeviation,whilequalitativevalueswere described asnumber (n) and percentage(%). For the comparisons of qualitativevariablesbetweengroups,thechi-squaredtestwas used,whiletheMann–Whitneytestwasusedforquantitative

variables.ThisstudywasapprovedbytheEthicsCommittee oftheCentroHospitalareUniversitáriodeCoimbra,andall patientsortheirrespectivefamiliessignedaninformed con-sentform.

Results

Sample comprised of 16 patients, nine males and seven females,withameanageof61.25years(29–87).Disarticulation surgerywasperformedaccordingtothetechniquesdescribed in the literature.3,4 _{Afterisolating and ligatingthe femoral}

0

Number of patients

1 2 3 4 5 6

Infection Tumor Trauma Ischemia

Fig.1–Reasonsforhipdisarticulation.

Table1–Descriptionoftheseriesofhipdisarticulations.

Cause Frequency (number)

Frequency (percentage)

Urgent dislocations (percentage)

Meanpost-surgerysurvival inpatientswhodied(days)

Mortality (percentage)

Complications

Infection 6 37.50 0 171.5 33.33 33.33

Tumor 5 31.25 0 416 60 60

Trauma 3 18.75 66.67 3 66.67 33.33

Ischemia 2 12.50 50 7 50 50

chondrosarcoma (n=3), pleomorphic sarcoma of the thigh (n=2),andbasalcelltumors(n=1).

The three polytraumatized patients in this series had extensiveslough inthe pelvisand thigh, withmulti-organ injuriesandneedformultidisciplinarytreatment.Allofthem showedhemodynamicinstabilityandonlyonesurvivedpast thefirstpostoperativeweek.Thecausesofischemiaverifiedin thesamplewereacutearterialischemiaduetofemoral arte-rialthromboembolismandiatrogeniclesionofthecommon femoralartery. Inthreepatients,onewithtraumaticlesion andtwowithischemiclesions,asupracondylaramputation ofthe femurwas initially performed, which, due to unfa-vorableevolutionandsuperinfection,ledtotheneedforhip disarticulation.Complicationswereobservedpostoperatively insevenpatients(43.75%),mainlysuperficialinfections(n=5), suturedehiscence(n=2),necrosisoftheamputationstump scar(n=2),and metastasisoftheamputationstump(n=1). Complicationsweremorecommonlyobservedin disarticu-lationsduetotumors(60%),whichcorrespondstothegroup withthelongestpost-surgicalsurvivaltime(416days).Atrend forhigherratesofcomplicationsinemergencysurgerieswhen compared with elective (66.67% vs. 38.50%) was observed, but withoutstatistical significance(p=0.55). Ahigher com-plicationrateinindividualswhounderwentsurgerypriorto disarticulationwasnotobserved.

Meanoverall post-surgicalsurvivaltimewas200.5days; whenthismanuscriptwasdrafted,onlyhalfofthepatients inthe samplewere alive.Survival rates were 68.75% after six months, 56.25% after one year, and 50% after three years. Mortality rates were higher in disarticulations due to trauma (66.7%)and tumor (60%). For the eightpatients who had died when this review was drafted, there was a tendency for lower survival time inthose who underwent emergency surgery (4.33±3.79 days) when compared with electivesurgery(318.20±318.01days),butwithoutstatistical significance(p=0.14).Inpatientswhoarealive,themost com-monreasonfordisarticulationwasinfection(50%),followed bytumor(25%);therewasonlyonecaseofischemiaandone caseoftrauma.

Meanlifeexpectancyofthosewhosurvivedformorethan three months after surgery was 205.5 days for bedridden patientsand588daysforthosewhowereabletowalk.Half ofthepatientswalkwithcrutcheswithoutprosthesisdueto intolerance to it,25% walkwithprosthetic limbs, and 25% arebedridden.Inthesixpatientswhoareabletowalk,the mostfrequentreasonfordisarticulationwasinfection(50%), followedbytumor(33.33%).Allthesepatientshavefrequent eventsofphantompainrequiringmedicaltreatment.

Discussion

Hipdisarticulationisacomplexandinfrequentsurgery,only performedasthelastoptioninextremecases.1,5_{Theliterature}

onthissurgeryisscarce,mainlyintheformofcasereportsand smallseries.5_{Areviewofthemostrelevantarticlesrelatedto}

hipdislocationsispresentedbelow.

Endeanetal.6_{analyzedaseriesof53hipdislocations}

mortality rate was significantly higher in urgent surgeries (33%)whencomparedwithelectivesurgeries(4%).Presence of ischemia associated with limb infection and heart dis-easewasthegreatestpredictorofmortality.DénesandTill7

analyzedaseriesof63dislocations,whoseindicationswere arterialischemia(n=34),tumor(n=24),andinfection(n=4). Surgical wound complications were observed in 64.86% of the patients whosedisarticulation had vascular cause and in20.83%ofthose withtumorcause.Themortalityrate in thefirst postoperativemonth rangedfrom 43.24%inthose withavascular cause to0%inthose causedbytumor. All patientswhounderwentdisarticulationduetoatumorwere able to walk with a prosthetic limb; in contrast, of those whoseetiologywasvascular,onlytwousedprosthesesand 19becamewheelchair-dependent.Unruhetal.8_presenteda

seriesof38hipdislocationsover11yearsofexperience.Four patientsweredisarticulatedbilaterallyand20ofthe disartic-ulationsoccurredinapreviouslyamputatedlimb,13ofthem duringthesamehospitalizationperiod.Indicationsfor disar-ticulationswereischemiasecondarytoatherosclerosis(n=17), femoralosteomyelitis(n=10),andtrauma(n=11).Theauthors reportedpost-operativeinfections(63%)asthemostfrequent complication.Inthepostoperativeperiod,septicshock(21%), hemorrhagicshock(11%),disseminatedcoagulopathy(11%), acuterenalfailure (24%),and cardiac(26%)and pulmonary (24%)dysfunctionswereobserved.Meanmortalityratewas 44%:60%incasesofischemiaassociatedwithinfection,20% incasesofischemiawithoutinfection,22%incasesoffemoral osteomyelitis,100%incasesoftraumaassociatedwith infec-tion,and 33% incases oftraumawithout infection. Those authors stated that the presenceof preoperative infection tripledtheriskofdeathafterhipdisarticulation.Regarding functionality,theyobservedthatnoneofthe19survivorswere abletousetheprostheticlimb,onlyfourwereabletowalk withawalker,12werewheelchair-dependent,andthreewere bedridden.Fenelonetal.9_{presentedaseriesof11}

disarticula-tionssecondarytoinfectioncomplicationsofhiparthroplasty. Indicationsfordisarticulationwereseverefistulizingsoft tis-sueand femurinfections, onecaseofpronouncedfemoral boneloss,and onecaseofrupturedfalseaneurysmofthe externaliliac artery.Disarticulationwasurgentinsixcases andelective intheremainder;no deathswere observedin theperioperativeperiod.Themostcommonlyfound microor-ganismswereStaphylococcusaureus,Pseudomonas,andProteus; 81.82%ofthedisarticulatedpatientshadalreadyundergone fourormorehiparthroplastyrevisionsurgeries.Theauthors suggest that some dislocations could have been avoided if a resection arthroplasty had been performed instead of repeatedprosthesisrevisions.Assessingthefunctionalresults oftheeightsurvivorsatthetimeofthereview,sixpatients wereabletowalk,fourwithwalkersandtwowithprosthetic limbs,andtwowerebedridden.Therewerealsothreecasesof surgicalwoundcomplicationsandtwocasesofphantompain. LászlóandKullmann10_{studied29hipdislocationsofischemic}

originandalsofoundahighrateofsurgicalwound complica-tions.Healingbyfirstintentiononlyoccurredintwocases; scarringby second intention with superficial necrosiswas observedin13cases,andtherewere12casesofdeep necro-sis.Themortalityrateintheperioperativeperiodwas37%. Onlytwopatientsregularlyusedtheprostheticlimb.Itwas

observedthatthemortalityratewashigherwhenpatientshad undergonepreviousdistalamputations.Mostofthepatients had undergoneamean of2.3priordistalamputations and 2.9conservativelimbsurgeries.Theseauthorsconcludedthat surgicalaggression increasesthe riskofmortalityand that amputationmustfirstbeperformedattheappropriatelevel, soasnottosubjectthepatienttoseveralsurgeries.Another studyof15dislocationsduetoinfection,sevendueto necro-tizinginfectionsandeightduetopersistentinfectionsofthe proximalthigh, indicatedthatthemostcommonpathogen wasStaphylococcusaureus,presentineightpatients.5

Surger-ieswereelectiveineightpatientsandemergenciesinseven. Allpatientssurvivedsurgery;onlyonedeathwasrecorded,on the29thdayafterdisarticulation.5_{Theauthorsconcludedthat}

hipdisarticulationastreatmentofsevereinfectionsofthehip andgroincanresultinhighlevelsofsurvival,evenincases ofemergencysurgery,andtheyattributetheseresultsto mul-tidisciplinaryinvolvement,andtotheexperienceinsurgical andpost-surgicaltreatmentperformedintheintensivecare unitattheirinstitution.5_Jainetal.11_{studied80dislocations,}

exclusively duetotumor, and foundthatthe predominant histologictypeswereosteosarcoma(n=27),chondrosarcoma (n=8),leiomyosarcoma(n=8),andliposarcoma(n=6).In52.5% ofthecases,disarticulationwasperformedasthefirstsurgery, whileintheremainder,surgerywasperformedduetolocal recurrenceafteranattemptoflimb-sparingsurgery.The five-yearsurvivalrateofprimarydisarticulationwas32%,whilefor localrecurrenceitwas25%.Thereweretencasesoflocal recur-renceafterdisarticulationwithinadequateresectionmargins. Of the 11 patients who answered the questionnaire about functionality,onlyonewasabletouseaprostheticlimb regu-larly;eightpatientsreportedphantompain.

Inthepresentsample,weobservedthatmost disarticula-tionsduetoinfectionoccurredinthecontextofpatientswith largetumorprostheses,whichisinagreementwithhigher riskofthesereconstructionstodevelopinfection,notonlydue tothelengthandsurgeryduration,butalsotothe immuno-compromisedstatusofpatients.12_{Predictably,complications}

after hip disarticulationare frequent, not only due to the extent of surgery, but also because patients often present extremesituations,withmultiplecomorbiditiesand hemody-namicinstability.Theliteraturepresentscontroversialresults onmortalityafterhipdisarticulation;theratesvaryaccording totheindication,clinicalstatusofthepatient,andthedegree ofurgencyofthesurgery.6–10_{Inthepresentstudy,itisevident}

thatthebestsurvivalrateswereobservedinelectivesurgery, particularlyininfectiousandtumorcauses.Conversely,severe polytraumapatients,inemergencysituationsandoften asso-ciatedwithhemodynamicinstability,presenttheworstresults intermsofsurvivalandmortalityrate.Thefewstudiesthat analyze functional results afterhip disarticulation demon-stratedthatpatientspresentpoorqualityoflifeandsignificant difficultiesintherecoveryofthegaitandintheuseof sub-stitution prosthesisforthelower limb.7–9,11,13,14 _Theenergy

expenditure forgaitinpatientsundergoinghip disarticula-tionincreasesby82%,thusthepatientisoftenconfinedtoa wheelchairorbedridden.5,8,15_{Furthermore,Nowroozietal.}15

presentstudy,ashalfofthesurvivorswalkwithcrutches with-outtheuseoftheprostheticlimb,whileonly25%canusethe prosthesis.DénesandTill.7_{reportedthatfunctionalsuccess}

dependsonthecauseofdisarticulationandadvocatethat,in general,thoseduetotumorandtraumaarebettersuitedto gaitthanthoseduetovascularconditions.Inthepresent sam-ple,themostcommonreasonsfordisarticulationinpatients whoarecurrentlyabletowalkwereinfectionandtumors;the onlylivingpatientwithanischemicconditionisbedridden. Individualmotivation,age,overallhealthstatus,and comor-biditiesofthepatientareconsideredtobecrucialfactorsfor recoveryofgait.11

Thelimitationsofthepresentstudywerethesmallnumber ofindividualsinthesampleandthefactthatitwasa retro-spectiveobservationalstudy.Largersamplescouldprobably changesomeofthestatisticaltrendsintostatistically signifi-cantdifferences.

Conclusions

Hip disarticulation is a highly mutilating and last-resort surgery,withobviousimplicationsforlimbfunctionalityand highratesofcomplicationsandmortality.However,when per-formedinthepropertimewindowandwithcorrectindication, it isa life-saving surgerythat allowsthe patient toreturn home.Forthesuccessofthissurgicalprocedure,early identi-ficationofhipdisarticulationindicationsisparamount;soas nottopostponeanunavoidablesituationand consequently aggravatetheprognosis.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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retrospectiveanalysisof45oncologicalcases.WorldJSurg Oncol.2009;7:15.

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